quent interference with the digestive process, conditions most inviting for the manufacture of various poisons, that being absorbed into the circulation, should be just as capable of irritating the nerves as are Alcohol, Lead, etc. The exact nature of the poison has not, however, as yet, been determined.

Another explanation of the disturbance of the nervous system in malignant disease is that of deranged nutrition dependent on the Malignant Cachexia. That, however, toxins are the more probable causes of the nerve lesions in cancer is, I believe, to-day the accepted belief.

That the nervous system can be disturbed in Cancer of the Stomach is proven by the rather frequent complication of Coma, and the rather rare presence of Tetany in this disease.

As to the rarity of Multiple Neuritis as a complication of Can. cer of the Stomach, Franz Riegel, in Nothnagel's Encyclopedia of Practical Medicine, states, that it is one of the rare complications, and he had up to 1903 collected only sixteen such cases, in fourteen of which, the diagnosis had been verified by an anatomical examination of the diseased nerves. After acareful perusal of the literature since 1903, we have been unable to obtain the report of a single case.

Multiple Neuritis is not so rare as a complication of Cancer located elsewhere in the body, and why the subject of Gastric Carcinoma should have been so singularly immune to this complication is a problem still awaiting solution.

The other interesting phase of the case appears to be that we had a patient who at autopsy showed such a marked cancerous tumor in the stomach, and yet during life made no allusion to his stomach at all.

The diagnosis was made through the marked cachexia, which spoke for cancer somewhere in the patient, and only after inquiries along the lines of malignancy, was the history obtained of a loss of blood from the stomach and intestines. Had the patient been seen two months before, at the time of the occur

rence of the bleeding, of course, attention would have been then called to the digestive tract; but in the absence of other evidence of malignancy, save age, might not Ulcer of the Stomach have then been more suggestive than Cancer, and if even the diagnosis of malignancy had been made at that time, might it not even then have been too late to offer the patient any hope from surgical interference?

The case emphasizes the fact of the great difficulty of an early diagnosis in these cases, though, of course, cancer of the body of the stomach gives fewer early symptoms than that of the pylorus. Some of the more recent workers in this field, especially the surgeons, have come to feel, that the diagnosis must be made through an exploratory operation, if the patient is to receive any benefit from surgery. This position is taken by such a clever worker as Wm. J. Mayo, who in a recent article, advocating exploratory operations in this cases, tells the Internist, that by the time he makes his diagnosis through examination of the stomach contents, investigation of disturbed motility, ectasis, tumor, etc., the patient is beyond all surgical aid, either through metastases, adhesions or cachexia. He thinks explorations should be made merely on suspicious symptoms, but, as yet, I have not been able to formulate from the writings of those who take this radical position, just what should constitute a symptom grouping, sufficiently suspicious to warrant the opening of the abdomen, unless we consider the symptoms of a persisting Gastric Catharrh in one at or past middle life, sufficient grounds upon which to advise exploratory operation; for in the early stage of this class of cases such is frequently the only evidence resulting from even a most painstaking examination. This is one of the points on which I should especially like to hear the views of the gentlemen present here to-night.

Dr. J. E. Noever, Jour. Med. de Brux., in an article published in the 1905 volume, page 694, on the early diagnosis of Cancer of the Stomach, recommends examinations of the stools for

blood. In sixty-two out of sixty-seven cases, he found blood in the stools, by the Boas method.* In regard to the examination of gastric fluid, he states, that hydrochloric acid is present in about from eleven to thirteen per cent of the cases, and more in carcinoma of the pylorus than of the lesser curvature. Hyperacidity is also present when cancer is associated with old ulcers or following nervous hyperacidity. Lactic acid is not pathognomonic of cancer, but is not produced in so great a quantity in other affections, nor is stasis necessary for its production. In cases with absence of lactic acid, and presence of hydrochloric acid, the difference between ulcer and cancer is determined as follows:

Gastric juice should be examined three times the same day, as follows:

The first, fasting; the second, after a test meal of egg albumen; third, after a test meal of beefsteak. In ulcer he finds hydrochloric acid in all three tests. The absence or presence of a small quantity of hydrochloric acid in one or several of the examinations indicates mucous catharrh of the stomach, and mucous catharrh with other symptoms is in favor of carcinoma.

The transudation of albumen into the stomach is determined by allowing no albuminous food after mid-day. In the evening the stomach is washed out; next morning, while fasting, stomach is washed with a 400 cc. normal salt solution; if the liquid contains more than twenty mg. of nitrogen, in 100 cc. of stomach washing, or more than one-sixteenth to one-half in one-one

*Boas Method:

a. Triturate part of the stool with distilled water;

b. Add one part of mixture to one third volume of glacial acetic acid; c. Extract with ether;

d. Stir ethereal extract with a mixture of 30 drops of oil of turpentine and 10 drops of tincture of guaiac;

The blue color resulting is made more definite by adding distilled water and chloro form.

thousandth, of albumen, the presumption is in favor of can

.cer.

He considers an early exploratory operation should be made when a sufficient number of symptoms of beginning Carcinoma is present.

These are merely a few points which may be of aid in an early diagnosis of cancer of the stomach.

ACUTE LYMPHATIC LEUKAEMIA.

BY L. H. HEMPELMANN, M.D., ST. LOUIS, MO.

Acute Lymphatic Leukaemia is a rare disease which was not recognized as a clinical entity until 1895, when Fraenkel1 reported ten cases studied by him at the Urban Krankenhaus, Berlin. He also gave us the first accurate description of the blood in this terrible malady. He describes the predominating leucocyte as from one to three times the size of the blood cell with large nuclei nearly filling the cell and having only a narrow zone of protoplasm about the nucleus. The nuclei are round or oval and stain fairly intensely, but do not show any distinct chromatin network.

The typical small lymphocytes while absolutely increased are much less numerous than these large cells and the polymorphonuclears are relatively and indeed often absolutely decreased. Myelocytes and Eosinophiles are absent as are also nucleated red cells.

These cases differ radically from the chronic cases as they are usually accompanied by fever and have a marked tendency to hemorrhages, which has often led to the erroneous diagnosis of scurvy or morbus maculosus Werlhofii. The spleen and lymphatic glands, if enlarged at all, are only moderately so. The disease runs its fatal course in from four and a half days to two months.

Its etiology remains unknown; several observers have isolated streptococci from the blood, but these are probably the result rather than the cause of the trouble. It is more frequent in males than in females.